During the public health emergency, the Centers for Medicare & Medicaid Services (CMS) waived the statutory requirement, 42 U.S.C. §1395x(i), limiting Medicare Part A coverage in skilled nursing facilities (SNFs) to beneficiaries who have a prior inpatient hospital stay of at least three consecutive days. “Medicare Skilled Nursing Facility Use and Spending Before and After Introduction of the Public Health Emergency Waiver During the COVID-19 Pandemic,” a study of 100% of claims in traditional Medicare for inpatient and SNF stays between January 1, 2017 and December 31, 2021, finds that the waiver resulted in a “marked increase [from 6% from January 2018 through February 2020 to 32% in March 2020 to September 2021] in the prevalence of SNF episodes without a preceding hospitalization, especially in the first year of the COVID-19 pandemic.”
Increased use of this waiver was most common in for-profit and rural facilities that used the waiver for their long-term care, dually eligible residents, many of whom had COVID-19, in a process described by the Medicare Payment Advisory Commission as “skilling-in-place.” Nursing facilities using the waiver had lower overall star ratings and lower staffing levels than other facilities. Most community-living beneficiaries whose Part A stay was covered by the waiver had spent some time in an acute care hospital. Widespread use of vaccinations in 2021 led to declining use of the waiver.
An Invited Commentary, “A Brief History of the 3-Day Hospital Say Rule,” suggests that it may be “time to revisit the reasonableness of the 3-day prior hospital stay rule,” citing the waiver of the rule by most Medicare managed care plans and many accountable care organizations.
May 4, 2023 – T. Edelman